INTRODUCTION- Appendicitis remains the most common acute surgical condition of the abdomen. Hyperbilirubinemia (elevated serum bilirubin) is accumulation of bilirubin above physiological level in blood stream. Elevated serum bilirubin levels in acute appendicitis can either appear as a result of bacteremia, or endotoxaemia, both possible in the catarrhal and phlegmonous forms as well as in the gangrenous or perforated cases. The bacteria present in the portal blood are usually cleared by detoxication and immunological action of reticuloendot helial system of liver that act as rst line defence in clearing toxic substances, bacteria and their products. But when bacterial load overwhelms the Kupffer Cell function, the damage to hepatocytes is reected in serum bilirubin levels alone or in combination with liver enzymes depending upon the type, severity and site of lesion.[1]Jaundice has been associated with appendicitis and studies have shown hyperbilirubinemia as a predictor of appendiceal perforation. [2,3] MATERIAL & METHODS- The study included 100 patients diagnosed to have acute appendicitis clinically, with raised white blood cell count ( >= 10,000 /cmm) warranting emergency, operative intervention. The liver enzymes and bilirubin levels were noted. Subsequently these cases were operated and clinical diagnosis was conrmed intra-operatively and post- operatively by histo-pathological examination. Their clinical and investigative data were compiled and analysed. RESULTS & DISCUSSION- Out of the 100 patients recruited in the study, all had appendiceal inammation on histo-pathological analysis. Of the 100, histo-pathological analysis of 25 (25%) revealed a gangrenous appendicitis and 3 (3%) cases revealed perforated appendicitis. Of the 25 patients of gangrenous appendicitis, 20 (80%) patients had elevated bilirubin levels and/or liver enzymes. 1 (33.33%) of the 3 patients of appendiceal perforation had elevated bilirubin levels. Remaining 72 cases had normal or marginally elevated levels of bilirubin. Overall sensitivity was 75% and specicity was 72%. The mechanism outlined is invasion of the Gram-negative bacteria through the muscularis propria of the appendix, leading to direct invasion or translocation of the germs in the portal system and the liver, interfering with bilirubin excretion through bile ducts by endotoxin action. The presence of jaundice in sepsis is well documented, especially associated with Gram-negative pathogens [4,5,6]. The hemolysis produced by certain bacteria (including E. coli), produces an increase in indirect and total serum bilirubin [7]. Also, some endotoxins released in the peripheral blood stream are responsible for impeding the liver's mechanism for bilirubin uptake and canalicular excretion [8,9]. Endotoxins produce cholestasis by damaging biliary salt transport through cytokine mediated mechanisms [10,11]. Estrada et al. have formulated the hypothesis that jaundice can be associated with perforation of the appendix, serving as a severity marker [12]. They explain the elevated STB by the invasion of the Gram-negative bacteria through the muscularis propria of the appendix, leading to direct invasion or translocation of the germs in the portal system and the liver, interfering with bilirubin excretion through bile ducts by endotoxin action. Emmanuel et al. nd that STB has a specicity of 88% and a positive predictive value of 91% for perforated acute appendicitis [13], while Sand et al nd an 86% specicity for gangrenous or perforated forms, compared with only a 35% specicity of the C reactive protein. Hong, on a large series of 1195 patients, also nds as signicant the value of STB in the identication of perforation [14]. CONCLUSION- Broadly, we can say that hyper-bilirubinemia is a sensitive and specic, cheap pre-operative marker of gangrenous, perforated appendicitis. Table 1- Type of Appendicitis and Frequency with Hyperbil irubinemia HYPERBILIRUBINEMIA- A MARKER FOR GANGRENOUS AND PERFORATED APPENDICITIS Original Research Paper Dr. Amar Chandrakant Holambe MBBS PG Resident, Dept of General Surgery, Smt Kashibai Navale Medical College & General Hospital, Pune-411041, Maharashtra, India General Surgery Appendicitis is the most common acute surgical condition of the abdomen. Simple case of appendicitis can progress to perforation within 48hrs of attack of acute appendicitis, which increases both morbidity and mortality. Cholestasis and portal pyemia form the basis for sepsis in cases of appendicitis and the present study aimed to evaluate the co-relation of hyperbilirubinemia and severity of appendicitis. ABSTRACT KEYWORDS : Appendicitis, Hyperbilirubinemia, Gangrenous, Perforated VOLUME-9, ISSUE-1, JANUARY-2020 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra Dr. Snehal Nachiket Purandare* MBBS, MS-General Surgery Professor, Dept of General Surgery, Smt. Kashibai Navale Medical College & General Hospital, Pune-411041, Maharashtra, India*Corresponding Author HISTO- PATHOLOGY FREQU ENCY DAY OF PRESENTATION AFTER ONSET OF PAIN NO. OF CASES WITH HYPERBILIRUBIN EMIA Appendicitis (without gangrene/perf oration) 72 st th1 -4 day 0 Gangrenous Appendicitis 25 th th5 -7 day 20 (80%) Perforated Appendicitis 3 th th8 -12 day 1 (33.33%) 58 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS Table 2- Bilirubin Levels in Cases of Gangrenous & Perforated Appendicitis REFERENCES 1. Khan S. Evaluation of hyperbilirubinemia in acute inammation of appendix: a prospective study of 45 cases. Kathmandu University Med J. 2006;4(3):287-9. 2. Estrada JJ, Petrosyan M, Barhart J. Hyperbilirubinemia in appendicitis: a new predictor of perforation. J Gastrointest Surg. 2007;11:714-8. 3. Emmanuel A, Murchan P, Wilson I, Balfe P. The value of hyperbilirubinemia in the diagnosis of acute appendicitis. Ann R Coll Engl. 2011;93:213-7. 4. Whitehead MW, Hainsworth I, Kingham JG. The causes of obvi- ous jaundice in South West Wales: perceptions versus reality. Gut. 2001;48(3):409-13. 5. Chand N, Sanyal AJ. Sepsis-induced cholestasis. Hepatology. 2007;45(1):230- 41. 6. Orban C. Diagnostic criteria for sepsis in burn patients. Chirurgia (Bucur). 2012;107(6):697-700. 7. Shander A. Anemia in the critically ill. Crit Care Clin. 2004; 20(2):159-78 8. Roelofsen H, van der Veere CN, Ottenhoff R, Schoemaker B, Jansen PL, Oude Elferink RP. Decreased bilirubin transport in the perfused liver of endotoxemic rats. Gastroenterology. 1994; 107(4):1075-84. 9. 11. Bolder U, Ton-Nu HT, Schteingart CD, Frick E, Hofmann AF. Hepatocyte transport of bile acids and organic anions in endo- toxemic rats: impaired uptake and secretion. Gastroenterology. 1997;112(1):214-25. 10. Green RM, Beier D, Gollan JL. Regulation of hepatocyte bile salt transporters by endotoxin and inammatory cytokines in rodents. Gastroenterology. 1996;111(1):193-8. 11. 13. Whiting JF, Green RM, Rosenbluth AB, Gollan JL. Tumor necrosis factor- alpha decreases hepatocyte bile salt uptake and mediates endotoxin- induced cholestasis. Hepatology. 1995;22(4 Pt 1):1273-8. 12. Estrada JJ, Petrosyan M, Barnhart J, Tao M, Sohn H, Towgh S, et al. Hyperbilirubinemia in appendicitis: a new predictor of per- foration. J Gastrointest Surg. 2007;11(6):714-8. 13. Emmanuel A, Murchan P, Wilson I, Balfe P. The value of hyper- bilirubinaemia in the diagnosis of acute appendicitis. Ann R Coll Surg Engl. 2011;93(3):213-7 14. Hong YR, Chung C-W, Kim JW, Kwon CI, Ahn DH, Kwon SW, Kim SK. Hyperbilirubinemia is a signicant indicator for the severity of acute appendicitis. J Korean Soc Coloproctol. 2012;28(5):247-52. VOLUME-9, ISSUE-1, JANUARY-2020 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra LIVER FUNCTION TEST REFERENC E VALUES GANGRENOUS APPENDICITIS PERFORATED APPENDICITIS Total Bilirubin 0.2-1.2 1.6-2.4 2.8 Direct Bilirubin 0.0-0.2 0.4-1.0 1.4 Indirect Bilirubin 0.2-1.0 0.8-1.2 1.4 SGOT Upto 45 45-56 59 SGPT Upto 45 45-56 62 ALP 53-128 55-156 154 X 59GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS